RMHP Monument ONE Bronze $7,700 ($0 Virtual Urgent Care + $0 Primary Care Visits, $3 T2 Preferred Rx) - 97879CO0380005 Health Insurance Plan
Rocky Mountain HMO, Inc. health insurance plan with the Plan ID 97879CO0380005. The plan is called RMHP Monument ONE Bronze $7,700 ($0 Virtual Urgent Care + $0 Primary Care Visits, $3 T2 Preferred Rx).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.98% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.02% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 97879CO0380005 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Colorado | ||||||||||||||||||
| Health Insurance Issuer | Rocky Mountain HMO, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 97879CO0380005-01 | ||||||||||||||||||
| Provider Network(s) | ['CON002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 97879CO0380005-01 |
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| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
RMHP Monument ONE Bronze $7,700 ($0 Virtual Urgent Care + $0 Primary Care Visits, $3 T2 Preferred Rx) Health Insurance Plan Variant 97879CO0380005-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 100% |
| Formulary ID | COF013 |
| HIOS Product ID | 97879CO038 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 64.98% |
| Issuer ID | 97879 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | CON002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Urgent/Emergent Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 97879CO0380005-01 |
| Plan Level Exclusions | Some exclusions may apply. See the applicable Evidence of Coverage for details. |
| Plan Marketing Name | RMHP Monument ONE Bronze $7,700 ($0 Virtual Urgent Care + $0 Primary Care Visits, $3 T2 Preferred Rx) |
| Plan Type | HMO |
| Plan Variant Marketing Name | RMHP Monument ONE Bronze $7,700 ($0 Virtual Urgent Care + $0 Primary Care Visits, $3 T2 Preferred Rx) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,300 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,700 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $4,500 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | COS002 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All, except OBGYN and as state mandated |
| Plan ID | 97879CO0380005 |
| State Code | CO |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $7700 per person | $15400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,700 |
| TEHBDedOutofNetFamily | per person not applicable | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $9100 per person | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of RMHP Monument ONE Bronze $7,700 ($0 Virtual Urgent Care + $0 Primary Care Visits, $3 T2 Preferred Rx) Health Insurance Plan, 97879CO0380005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about RMHP Monument ONE Bronze $7,700 ($0 Virtual Urgent Care + $0 Primary Care Visits, $3 T2 Preferred Rx), 97879CO0380005 Health Insurance Plan, 97879CO0380005
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Does RMHP Monument ONE Bronze $7,700 ($0 Virtual Urgent Care + $0 Primary Care Visits, $3 T2 Preferred Rx) Health Insurance Plan, 97879CO0380005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (97879CO0380005) Health Insurance Plan, Variant (97879CO0380005-01) have Out Of Country Coverage?
Yes. Details: Urgent/Emergent Only
Does (97879CO0380005) Health Insurance Plan, Variant (97879CO0380005-01) have Out of Service Area Coverage?
Yes. Details: Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API